The Methods of Reconstruction of Pancreatic Digestive Continuity After Pancreaticoduodenectomy: A Meta-Analysis of Randomized Controlled Trials

Background  

Pancreatic fistula (PF) is an important factor responsible for the considerable morbidity associated with pancreaticoduodenectomy (PD). There have been many techniques proposed for the reconstruction of pancreatic digestive continuity to prevent fistula formation but which is best is still highly debated. We carried out a systematic review and meta-analysis to determine the effectiveness of methods of anastomosis after PD.     

Immunopathologic and clinical studies in pulmonary hypertension associated with systemic lupus erythematosus

PH is an uncommon manifestation of SLE. The symptoms of PH develop within a few years after the onset of the multisystem disease. The most common presenting complaints of SLE patients with PH are dyspnea on exertion, chest pain, nonproductive cough, edema, and fatigue or weakness. The important physical findings are a loud second pulmonic heart sound and a right ventricular lift. The chest roentgenogram shows a cardiomegaly, a prominent pulmonary segment, and usually clear lung fields. Pulmonary function tests may show evidence of restrictive lung disease; however, the physiologic abnormalities are mild and out of proportion to the severity of the PH. The diagnosis of PH is established by cardiac catheterization showing elevated pulmonary artery pressure, normal capillary wedge pressure, and no evidence of intracardiac or extracardiac shunts. Pathologic examination of the lung demonstrates angiomatoid lesions involving muscular pulmonary arteries. There is a thickening of the media and subintima of the arterioles. Immunoglobulin and complement deposits are found in the walls of pulmonary arteries. Immunoglobulin eluted from the lung contains rheumatoid factor and antinuclear antibody including antibody to DNA activity. DNA antigen is also present in walls of blood vessels. These results suggest an immune complex deposition process as a mechanism in the pathogenesis of PH in SLE. The clinical course of PH in SLE is variable. Symptoms may be mild and the disease follows a stable and protracted course for several years. It can, however, develop a progressive course ending in death in a few years. The clinical response of SLE patients with PH to treatment with high doses of systemic corticosteroids is not consistent or predictable.     

Spinal anesthesia for cesarean section following inadequate labor epidural analgesia: a retrospective audit

BACKGROUND: High blocks have been reported when spinal anesthesia is used for cesarean section following inadequate labor epidural analgesia. We have therefore modified the practice at our institution to minimize this risk and conducted a retrospective observational study of outcome following the change of practice. METHOD: The records of 115 women with inadequate epidural labor analgesia who required cesarean section between July 1998 and January 2002 were studied. No epidural boluses were administered in the 30 min preceding spinal anesthesia and a reduced spinal dose, median (range) 9.38 mg (7.5-11.3 mg) of 0.75% hyperbaric bupivacaine and fentanyl 15 microg (10-25 microg) was used. Patients were left sitting for 2 min and then positioned supine with left uterine displacement and were closely monitored for symptoms or signs that would suggest a high block. RESULTS: No parturient developed a high spinal necessitating intubation, and there was no adverse neonatal outcome. CONCLUSION: These findings do not conclusively establish this method as safe, but should spinal anesthesia for cesarean section following suboptimal labor epidural analgesia be considered, avoiding epidural boluses immediately preceding spinal injection, using a lower spinal dose, and delayed supine positioning following spinal injection may be advisable.     

Sperm DNA damage and its clinical relevance in assessing reproductive outcome

The routine examination of semen, which assesses sperm concentration, percentage motility and morphology,does not identify subtle defects in sperm chromatin architecture. The focus on the genomic integrity of the male gamete has intensified recently due to the growing concern that genetic diseases may be transmitted via assisted reproductive techniques (ART). Accordingly, the intent of this review is to describe the details of the informationpertaining to mitochondfial/nuclear sperm DNA damage with an emphasis on its clinical significance and its relationship with male infertility. Assessment of sperm DNA damage appears to be a potential tool for evaluating semen samples prior to their use in ART. Testing DNA integrity may help select spermatozoa with intact DNA or with the least amount of DNA damage for use in assisted conception. In turn, this may alleviate the financial, social and emotional problems associated with failed ART attempts.     

Microcatheter navigation and thrombolysis in acute symptomatic cervical internal carotid occlusion

BACKGROUND AND PURPOSE: The treatment of acute stroke distal to an occluded cervical internal carotid artery (ICA) presents a challenge. We report our results of endovascular therapy in 7 patients presenting with acute symptomatic cervical ICA occlusion.PATIENTS AND TECHNIQUES: Among patients presenting with acute stroke at our institution from June 2001 to June 2005, we retrospectively identified 7 patients who underwent endovascular therapy of acute cervical ICA occlusion. The techniques used for vessel recanalization were analyzed. Postprocedure CT scans were reviewed for hemorrhage. The clinical outcomes were assessed by using the modified Rankin scale (mRS) with good outcomes assigned scores of ≤2.RESULTS: All 7 patients revealed cervical ICA occlusion, with additional intracranial thrombus in 6 of the 7 patients. In all patients, a guiding catheter was placed in the ipsilateral common carotid artery proximal to the occlusion and a microcatheter advanced through the ICA clot to deliver intra-arterial (IA) tissue plasminogen activator (in 6 patients, the microcatheter was also advanced intracranially for thrombolysis). Successful recanalization of the occluded ICA was achieved in 6 patients. In 3 patients, balloon angioplasty and stent placement of the cervical ICA was also performed. Follow-up CT in 6 patients showed small basal ganglia infarcts in 4, patchy parietal infarcts in one, and frontal lobe hematoma in one patient. At 1 month after the procedure, 5 patients had good clinical outcomes (mRS of 0 in 4 patients and 1 in one patient).CONCLUSION: Performance of IA thrombolysis by passing a microcatheter through an acutely occluded internal carotid artery may be an effective therapy in acute stroke.

The National Institute of Neurological Disorders and Stroke trial showed the benefit of intravenous (IV) tissue plasminogen activator (tPA) in patients presenting within 3 hours of onset of symptoms of acute stroke.¹ Recent studies have revealed promising results for intra-arterial (IA) thrombolysis especially in patients with significant clot burden that may be refractory to IV tPA.^2–5 At our institution, patients presenting with symptoms of acute stroke within 3 to 6 hours of onset who have thrombus in the M1 or M2 segments of the middle cerebral artery (MCA) are considered for IA thrombolysis. A unique subset of patients presenting with acute stroke may have an occluded MCA distal to an occluded internal carotid artery (ICA) just distal to the common carotid artery (CCA) bifurcation. Acute ICA occlusions may be embolic, related to atherosclerotic disease, or caused by dissections. These patients may have a poor response to IV tPA.⁶ The natural history of patients presenting with signs and symptoms of acute stroke distal to an acutely occluded cervical ICA is poor. There is a 16% to 55% likelihood of death from complications of infarction, 40% to 69% will be severely disabled, and only 2% to 12% will make a good recovery.⁷ There are various surgical options in acute symptomatic ICA occlusions, which include carotid endarterectomy (CEA), embolectomy, and surgical bypass. Patients with profound neurologic deficits or large infarcts, however, are at high risk for hemorrhagic transformation after CEA, thus making this a strong exclusion criterion in recent studies evaluating CEA.^8,9 In addition, the results of urgent surgical recanalization may not be ideal: 26.5% normal neurologic outcome after emergency CEA in a study by Meyer et al.⁷Catheter navigation through an acutely occluded ICA for the purpose of performing IA thrombolysis has been considered an obstacle and is an issue of debate.⁸ Several small case series have described successful IA thrombolysis in the territory of an acutely occluded cervical ICA.^8,10,11 Traversing the acutely occluded ICA segment combined with IA tPA may, however, uncover an underlying severe stenosis at the carotid bulb. The management of this residual stenosis or occlusion at the bulb presents an interesting challenge. Some authors have advocated acute angioplasty and stent placement at the time of thrombolysis.¹⁰ We report our results of urgent IA thrombolysis of acute MCA thrombus by navigating a microcatheter through an acutely occluded ICA and discuss the management of the underlying proximal ICA stenosis or occlusion in 7 patients presenting with acute stroke.     

Dose reduction in CT while maintaining diagnostic confidence: diagnostic reference levels at routine head, chest, and abdominal CT--IAEA-coordinated research project

PURPOSE: To measure radiation doses for computed tomography (CT) of the head, chest, and abdomen and compare them with the diagnostic reference levels, as part of the International Atomic Energy Agency Research coordination project. MATERIALS AND METHODS: The local ethics committees of all participating institutions approved the study protocol. Written informed consent was obtained from all patients. All scanners were helical single-section or multi-detector row CT systems. Six hundred thirty-three patients undergoing head (n = 97), chest (n = 243), or abdominal (n = 293) CT were included. Collected data included patient height, weight, sex, and age; tube voltage and tube current-time product settings; pitch; section thickness; number of sections; weighted or volumetric CT dose index; and dose-length product (DLP). The effective dose was also estimated and served as collective dose estimation data. RESULTS: Mean volumetric CT dose index and DLP values were below the European diagnostic reference levels: 39 mGy and 544 mGy . cm, respectively, at head CT; 9.3 mGy and 348 mGy . cm, respectively, at chest CT; and 10.4 mGy and 549 mGy . cm, respectively, at abdominal CT. Estimated effective doses were 1.2, 5.9, and 8.2 mSv, respectively. CONCLUSION: Comparison of CT results with diagnostic reference levels revealed the need for revisions, partly because the newer scanners have improved technology that facilitates lower patient doses.     

Surgical management of giant intracranial aneurysms

OBJECTIVES: The natural history of giant intracranial aneurysms is generally morbid. Mortality and morbidity associated with giant aneurysms is also higher than for smaller aneurysms. This study was carried out to assess the demographic profile, presenting features, complications, and outcome after surgical treatment of giant intracranial aneurysms. PATIENTS AND METHODS: A retrospective review of the medical records of all patients with giant intracranial aneurysms treated in the Department of Neurosurgery, Neurosciences Centre, All India Institute of Medical Sciences, New Delhi, from January 1995 through June 2007 was performed. The demographic profiles, presenting features, radiological findings, surgical treatments, and outcomes were assessed. RESULTS: A total of 1412 patients harboring 1675 aneurysms were treated. Out of these, 222 patients had 229 (13.7%) giant aneurysms, and of those, 181 aneurysms in 177 patients were managed surgically while 48 were treated with endovascular therapy. In the patients treated with surgery, common clinical presentations included subarachnoid hemorrhage (SAH) in 110 (62%) cases followed by mass effect in 57 (32%) cases. In patients who presented with SAH, the Hunt and Hess SAH grading was: grade I in 43 (39%), grade II in 40 (36%), grade III in 23 (21%), grade IV in two (2%), and grade V in 2 (2%) patients. One hundred and seven aneurysms (in 103 patients) were treated using direct surgical clipping. Forty-six patients with good collateral circulation were treated by gradual occlusion and ligation of the internal carotid artery (ICA) in the neck with a Silverstone clamp. Another nine patients with good collateral circulation, but persisting symptoms after ICA ligation, required trapping for obliteration of the aneurysm. Eleven patients with poor collateral circulation required extracranial-intracranial (EC-IC) bypass before proximal ICA ligation. A post-operative digital subtraction angiography (DSA) was performed in 118 patients and revealed well-obliterated aneurysm in 106 patients. The total treatment mortality rate was 9%. In the last 5 years, 117 patients were operated on with four operative deaths. Overall, the outcome was excellent in 131 (74.0%), good in 22 (12.4%), and poor in eight (4.5%) cases. CONCLUSIONS: It is concluded that 14% of all intracranial aneurysms are giant. The most common clinical presentation is SAH followed by features of an intracranial mass lesion. The cavernous ICA is the most common portion of the ICA affected. Direct surgical clipping is a safe and effective method of treatment and should be considered the first line of treatment whenever possible. With proper case selection, optimal radiological evaluation, and appropriate surgical strategy, it is possible to achieve a favorable outcome in almost 90% of the cases.     

CSF1R mutation presenting as dementia with Lewy bodies

Hereditary diffuse leukoencephalopathy with spheroids (HDLS) is an adult-onset autosomal dominant leukoencephalopathy resulting from mutations affecting the tyrosine kinase domain of the colony stimulating factor receptor 1 protein (encoded by CSF1R). The clinical phenotypes reported with CSF1R mutations are variable. We present a case of a patient with a pathogenic variant in the CSF1R gene with clinical and imaging features suggestive of Dementia with Lewy Bodies (DLB). This case expands the known clinical presentations associated with CSF1R mutations.